A guideline-based program may improve the outcome of stroke among illiterate patients

Education level is considered as an important factor for post-stroke functional outcome. Our previous study confirms the feasibility of SMART program to improve adherence of secondary stroke prevention in China.

We aim to investigate whether this program can influence the impact of educational level on post-stroke functional outcome in this sub-group analysis of SMART study.

We enrolled 3722 patients with acute ischemic stroke from multicenter (n = 47) SMART cohort. Patient's educational level was categorized as three: illiterate, 6th grade or lower, and 7th grade or higher. Functional outcome at six-month post-stroke was assessed by Modified Rankin Scale (mRS) and categorized as favorable (mRS: 0-2) or poor (mRS: 3-5). Binary logistic model, adjusting for age, gender, stroke history, hypertension, diabetes, hyperlipidemia, educational level, and NIHSS was performed, respectively, in SMART group and usual care group to evaluate the effect of the SMART program on stroke functional outcome among different educated patients.

In both groups, logistic regression analysis showed that poor functional outcome was independently associated with older age [OR(95% CI):1.81(1.41-2.33), p < 0.001(SMART); OR (95% CI):1.38 (1.09-1.73), p = 0.007(usual care)], higher baseline NIHSS [OR (95% CI): 2.90 (2.38-3.53), p < 0.001(SMART); OR (95% CI): 2.82 (2.32-3.44), p < 0.001(usual care)], and diabetes [OR(95% CI):1.88 (1.18-3.00), p = 0.008(SMART); OR (95%CI):1.68 (1.03-2.73), p = 0.037(usual care)]. Compared to illiterate, higher educational levels were independently associated with favorable outcome in usual care group [OR (95% CI): 0.43 (0.20-0.93), p = 0.032 (6th grade or lower) and OR (95% CI): 0.40 (0.19-0.84), p = 0.016 (7th Grade or higher)], but not in SMART group (p = 0.806 and p = 0.889, respectively).

This study demonstrates that implementation of SMART program may improve post-stroke functional outcome among illiterate. This suggests special attention should be paid to illiterate patients with intensive education in order to improve post-stroke disability.